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DETERMINANTS OF NURSES’ PAIN MANAGEMENT

PRACTICES IN JORDAN: THE MODERATING ROLE OF

PATIENT’S BARRIERS

TITLE PAGE

BASHAR ISAM ALZGHOUL

DOCTOR OF PHILOSOPHY

UNIVERSITI UTARA MALAYSIA

April 2016

DETERMINANTS OF NURSES’ PAIN MANAGEMENT PRACTICES IN

JORDAN: THE MODERATING ROLE OF PATIENT’S BARRIERS

TITLE PAGE

By

BASHAR ISAM ALZGHOUL

Thesis Submitted to

School of Business Management

Universiti Utara Malaysia,

in Fulfillment of the Requirement for the Degree of Doctor of Philosophy

iv

PERMISSION TO USE

In presenting this thesis in fulfillment of the requirements for a Post Graduate degree

from the Universiti Utara Malaysia (UUM), I agree that the Library of this university

may make it freely available for inspection. I further agree that permission for copying

this thesis in any manner, in whole or in part, for scholarly purposes may be granted by

my supervisor(s) or in their absence, by the Dean of School of Business Management

where I did my thesis. It is understood that any copying or publication or use of this

thesis or parts of it for financial gain shall not be allowed without my written

permission. It is also understood that due recognition shall be given to me and to the

UUM in any scholarly use which may be made of any material in my thesis.

Request for permission to copy or to make other use of materials in this thesis in whole

or in part should be addressed to:

Dean of School of Business Management

Universiti Utara Malaysia

06010 UUM Sintok

Kedah Darul Aman

v

ABSTRACT

In spite of the significant advancement in methods and tools associated with pain

management, there is still a deficiency in the pain management practices. Therefore, the

aim of this study is to empirically determine the level of pain management practices,

evaluate the significant predictors of pain management practices (i.e. knowledge,

attitude, subjective norm and self-efficacy), examine the moderating effect of patient

barriers on the relationship between the predictors and the pain management practices,

and to investigate the applicability of Field theory in explaining the pain management

practices in Jordan. Six latent variables were involved including five exogenous and one

endogenous variables and a cross-sectional survey was used in conducting the study.

The instrument is consisted of 93 items adapted from the previous studies. The

questionnaires were distributed to 600 nurses in 13 hospitals located in the central region

of Jordan. The nurses were selected at random using a multistage cluster technique. Of

600, only 307 questionnaires were returned and used for analysis. Data collection was

carried out for the period of six months from October 2014 until March 2015. Data were

analyzed using partial least squares-structural equation modeling (PLS-SEM). The

findings support the majority of the hypothesized relationships, specifically the

hypothesized direct effects of attitude, self-efficacy, knowledge, and subjective norms

on the pain management practices. In addition, patient-related barriers moderate one of

these relationships. That is, the relationship between attitudes towards the pain

management and the pain management practices is weaker for nurses who perceived

high barriers from their patients as opposed to nurses who perceived low patient-related

barriers. Collectively, the determinant variables of pain management practices accounted

for 78% of the variance in the pain management practices. Theoretical, methodological,

and practical implications are discussed.

Keywords: Pain management practices, Knowledge, Attitude, Self-efficacy, Subjective

norm, Patients barriers, Jordanian hospitals

vi

ABSTRAK

Walaupun terdapat kemajuan yang ketara dalam kaedah dan alat-alat yang berkaitan

dengan pengurusan sakit, namun masih terdapat kekurangan dalam amalan pengurusan

sakit. Oleh itu, tujuan kajian ini adalah untuk menentukan secara empirikal tahap amalan

pengurusan sakit, menilai peramal yang ketara dalam amalan pengurusan sakit (iaitu

pengetahuan, sikap, norma subjektif dan keberkesanan diri), memeriksa kesan

penyederhana halangan pesakit mengenai hubungan antara peramal dan amalan

pengurusan sakit, dan menyiasat kesesuaian teori Field dalam menerangkan amalan

pengurusan sakit di Jordan. Enam pemboleh ubah pendam terlibat termasuk lima

eksogenus dan satu pemboleh ubah endogen. Kajian rentas telah digunakan dalam

menjalankan kajian ini. Alatan kajian terdiri daripada 93 item yang telah diadaptasi

daripada kajian sebelumnya. Soal selidik telah diedarkan kepada 600 jururawat di 13

hospital yang terletak di tengah Jordan. Jururawat telah dipilih secara rawak

menggunakan teknik kelompok berbilang. Dari 600, hanya 307 soal selidik telah berjaya

dikembalikan untuk dianalisis. Pengumpulan data telah dijalankan bagi tempoh enam

bulan iaitu dari Oktober 2014 hingga Mac 2015. Data telah dianalisis menggunakan

model separa persamaan kuasa dua struktur (PLS-SEM). Hasil kajian menyokong

majoriti hubungan hipotesis, khususnya kesan langsung hipotesis sikap, keberkesanan

diri, pengetahuan, dan norma subjektif mengenai amalan pengurusan sakit. Di samping

itu, halangan berkaitan dengan pesakit menyederhana satu daripada hubungan ini, iaitu,

hubungan antara sikap terhadap pengurusan sakit dan amalan pengurusan sakit adalah

lebih lemah untuk jururawat yang menerima halangan yang tinggi dari pesakit mereka

berbanding dengan jururawat yang menerima halangan yang rendah berkaitan dengan

pesakit. Secara kolektif, pemboleh ubah penentu amalan pengurusan sakit menyumbang

78% daripada kepelbagaian dalam amalan pengurusan sakit. teori, metodologi, dan

implikasi praktikal turut dibincangkan.

Kata kunci: Amalan pengurusan sakit, Pengetahuan, Sikap, Keberkesanan Diri, Norma

subjektif, Halangan pesakit, Hospital Jordan

vii

ACKNOWLEDGEMENT

In the name of ALLAH, the most gracious, the most merciful. Praise be to ALLAH, the

creator and custodian of the universe. Salawat and Salam to our Prophet Muhammad,

peace and blessings of ALLAH be upon him and to his family members, companions

and followers.

First and foremost, I thank Allah (S.W.T) for bestowing me with the much-

needed patience, perseverance, and persistence to accomplish this study. Second, I

would like to acknowledge my supervisor, Dr. Nor Azimah Chew Abdullah, for her

assistance, support, guidance, and encouragement during all the stages of my doctoral

study. Also, I would like to express my heartfelt gratitude to my wife, Isra‘a, and to my

son, Hamzah, for their constant love and support. Additionally, I would also like to

thank my parents, Isam and Hana, for their encouragement and instilling in me the value

of education. Finally, I would like to thank my brothers, Mohammad and Loay, and to

my sister, Sana‘a, who were so supportive during my years of study.

viii

TABLE OF CONTENTS

Page

TITLE PAGE .................................................................................................................... i

CERTIFICATION OF THSIS WORK ......................................................................... ii

PERMISSION TO USE .................................................................................................. iv

ABSTRACT ...................................................................................................................... v

ABSTRAK ....................................................................................................................... vi

ACKNOWLEDGEMENT ............................................................................................ vii

TABLE OF CONTENTS ............................................................................................. viii

LIST OF TABLES ........................................................................................................ xii

LIST OF FIGURES ...................................................................................................... xiv

LIST OF APPENDICES ............................................................................................... xv

LIST OF ABBREVIATIONS ...................................................................................... xvi

CHAPTER ONE: INTRODUCTION ............................................................................ 1

1.1 Background of the Study .......................................................................................... 1

1.2 Problem Statement ................................................................................................... 5

1.3 Research Questions ................................................................................................ 10

1.4 Research Objectives and Study Aim ...................................................................... 11

1.5 Scope of the Study .................................................................................................. 11

1.6 Significance of the Study ....................................................................................... 13

1.7 Summary and Overview of the Thesis ................................................................... 16

CHAPTER TWO: LITERATURE REVIEW ............................................................. 18

2.1 Introduction ............................................................................................................ 18

2.2 Contextual Information regarding Healthcare Sector in Jordan ............................. 18

2.3 Overview of Pain .................................................................................................... 21

2.3.1 Pain Theories ................................................................................................... 23

2.4 Overview of Pain Management .............................................................................. 24

2.4.1 Pain Assessment Phase .................................................................................... 24

2.4.2 Pharmacological and Non-pharmacological Intervention Phase ..................... 25

2.4.3 Pain Reassessment Phase ................................................................................. 29

2.5 Underpinning Theory ............................................................................................. 36

2.5.1 Field Theory ..................................................................................................... 36

2.6 Review of Past Studies ........................................................................................... 38

2.6.1 Pain Management Practices ............................................................................. 39

ix

2.6.2 Attitude towards Pain Management ................................................................. 45

2.6.3 Relationship between Attitude towards Pain Management and Pain

Management Practices ..................................................................................... 48

2.6.4 Self-efficacy of Pain Management .................................................................. 52

2.6.5 Relationship between Self-efficacy of Pain Management and Pain

Management Practices ..................................................................................... 53

2.6.6 Knowledge of Pain Management ..................................................................... 55

2.6.7 Relationship between Knowledge of Pain Management and Pain Management

Practices ........................................................................................................... 59

2.6.8 Subjective Norm towards Pain Management................................................... 62

2.6.9 Relationship between Subjective Norm towards Pain Management and Pain

Management Practices ..................................................................................... 63

2.6.10 Moderator Effect of Patient-related Barriers ................................................. 65

2.7 Literature Gap and Contributions ........................................................................... 70

2.8 Chapter Summary ................................................................................................... 73

CHAPTER THREE: THEORETICAL FRAMEWORK AND RESEARCH

METHODOLOGY ......................................................................................................... 74

3.1 Introduction ............................................................................................................ 74

3.2 Research Design ..................................................................................................... 74

3.3 Population, Sample Size and Sampling Technique ................................................ 76

3.3.1 Population ........................................................................................................ 76

3.3.2 Sample Size...................................................................................................... 78

3.3.3 Sampling Technique ........................................................................................ 80

3.4 Research Framework .............................................................................................. 89

3.5 Hypotheses of the Study ......................................................................................... 91

3.5.1 Attitude towards Pain Management and Pain Management Practices ............ 91

3.5.2 Self-efficacy of Pain Management and Pain Management Practices .............. 92

3.5.3 Knowledge of Pain Management and Pain Management Practices ................ 94

3.5.4 Subjective Norm towards Pain Management and Pain Management Practices

......................................................................................................................... 95

3.5.5 Moderator Effect of Patient-related Barriers ................................................... 96

3.5.6 Summary of Hypotheses .................................................................................. 99

3.6 Operational Definition of the Study Variables ..................................................... 100

3.7 Data Collection ..................................................................................................... 101

3.8 Instrumentation ..................................................................................................... 103

3.9 Pre-testing of the Questionnaire ........................................................................... 109

x

i. Content Validity................................................................................................... 109

ii. Face Validity....................................................................................................... 110

3.10 Data Analysis ..................................................................................................... 110

i. Descriptive Analysis ............................................................................................ 111

ii. Partial Least Squares (PLS) Technique .............................................................. 111

3.11 Ethical Considerations ........................................................................................ 112

3.12 Chapter Summary ............................................................................................... 113

CHAPTER FOUR: DATA ANALYSIS ................................................................. 114

4.1 Introduction .......................................................................................................... 114

4.2 Response Rate ...................................................................................................... 115

4.3 Data Screening and Preliminary Analysis ............................................................ 116

4.3.1 Missing Value Analysis ................................................................................. 116

4.3.2 Assessment of Outliers .................................................................................. 117

4.3.3 Normality Test ............................................................................................... 119

4.3.4 Multicollinearity Test .................................................................................... 123

4.4 Non-Response Bias .............................................................................................. 126

4.5 Common Method Variance .................................................................................. 129

4.6 Descriptive Statistics ............................................................................................ 131

4.6.1 Descriptive Statistics for Participants' Profile ............................................... 131

4.6.2 Descriptive Statistics for Questionnaire Constructs ...................................... 132

4.7 Assessment of Pain Management Practices Level ............................................... 133

4.8 Assessment of PLS-SEM Path Model Results ..................................................... 136

4.8.1 Outer Model Evaluation................................................................................. 137

4.8.2 Inner Model Evaluation ................................................................................. 147

4.9 Summary of Findings ........................................................................................... 158

4.10 Chapter Summary ............................................................................................... 159

CHAPTER FIVE: DISCUSSION AND CONCLUSION ......................................... 161

5.1 Introduction .......................................................................................................... 161

5.2 Recapitulation of the Study‘s Findings ................................................................ 161

5.3 Discussion of Research Findings ......................................................................... 163

5.3.1 Nurses‘ Pain Management Practices Level ................................................... 163

5.3.2 Attitude towards Pain Management and Pain Management Practices .......... 164

5.3.3 Self-efficacy of Pain Management and Pain Management Practices ............ 166

5.3.4 Knowledge of Pain Management and Pain Management Practices .............. 167

xi

5.3.5 Subjective Norms towards Pain Management and Pain Management Practices

....................................................................................................................... 169

5.3.6 Moderating Effect of Patients-related Barriers .............................................. 170

5.4 Implications of the Study ..................................................................................... 172

5.4.1 Practical Implications .................................................................................... 173

5.4.2 Theoretical Implications ................................................................................ 174

5.5 Limitations and Future Research Directions ........................................................ 177

5.6 Conclusions .......................................................................................................... 179

REFERENCES ............................................................................................................. 180

xii

LIST OF TABLES

Table Page

Table 2. 1 Summary of Previous Studies on the Relationship between Attitude and Pain

Management Practices................................................................................... 51

Table 2. 2 Summary of Previous Studies on the Relationship between Self-Efficacy of

Pain Management and Intention to Perform Pain Management ................... 54

Table 2. 3 Summary of Previous Studies on the Relationship between Knowledge of

Pain Management and Pain Management Practices ...................................... 61

Table 2. 4 Summary of Previous Studies on the Relationship between Subjective Norm

towards Pain Management and Intention to Perform Pain Management ...... 65

Table 3. 1 Types of Hospitals, Number of Hospitals and Beds in Jordanian Health

Sectors (2012) ............................................................................................... 77

Table 3. 2 Number of Registered Nurses in Each Category of the Public Sector ........... 78

Table 3. 3 Cluster Sampling Technique Steps ................................................................ 84

Table 3. 4 Number of Registered Nurses and Population for Each Hospital in the Public

Sector at Central Province of Jordan ............................................................. 88

Table 3. 5 Summary of the Study Hypotheses .............................................................. 100

Table 3. 6 Operational Definitions for the Study Variables.......................................... 101

Table 3. 7 Summary of Original and Direct Sources of Each Variable Scale .............. 105

Table 4. 1 Response Rate of the Questionnaire ............................................................ 115

Table 4. 2 Number and Percentage of Missing Values ................................................. 117

Table 4. 3 Univariate Outlier Test (z-score) ................................................................. 118

Table 4. 4 Multivariate Outlier Detected and Removed ............................................... 119

Table 4. 5 Correlation Matrix of the Exogenous Latent Constructs ............................. 125

Table 4. 6 Tolerance and Variance Inflation Factors (VIF) .......................................... 126

Table 4. 7 Results of Independent-Samples T-test for Non-Response Bias ................. 128

Table 4. 8 Demographic Characteristics of Participants ............................................... 132

Table 4. 9 Descriptive Statistics of Latent Variables .................................................... 133

Table 4. 10 Learning Outcomes of Multiple Choice Examinations ............................. 133

Table 4. 11 Frequency, Percentage, Minimum and Maximum Score, Mean, and

Standard Deviation of the Level of Nurses‘ Pain Management Practices (N =

266).............................................................................................................. 135

Table 4. 12 Frequency and Percentage of the Five Highest Orders of ―Constantly‖ and

the Five Highest Orders of ―Never‖ of Nurses‘ Pain Management Practices

(N = 266) ..................................................................................................... 136

Table 4. 13 Composite Reliability ................................................................................ 140

Table 4. 14 Average Variance Extracted ....................................................................... 142

xiii

Table Page

Table 4. 15 Latent Variable Correlations and Square Roots of Average Variance

Extracted...................................................................................................... 144

Table 4. 16 Loadings, Composite Reliability, and Average Variance Extracted ......... 145

Table 4. 17 Structural Model Assessment with Moderator (Full Model) ..................... 149

Table 4. 18 Variance Explained in the Endogenous Latent Variable ........................... 151

Table 4. 19 Effect Sizes of the Exogenous Latent Variables on Endogenous Latent

Variable Based on Cohen‘s (1988) Guideline............................................. 152

Table 4. 20 Construct Cross-validated Redundancy for Endogenous Latent Variable. 154

Table 4. 21 Strength of the Moderating Effects Based on Cohen‘s (1988) Guideline . 157

Table 4. 22 Summary of Hypotheses Testing ............................................................... 158

xiv

LIST OF FIGURES

Figure page

Figure 2. 1 Percentage of beds in each health sector of the total number of hospital beds

in Jordan ........................................................................................................ 20

Figure 2. 2 Numeric pain rating scale .............................................................................. 30

Figure 2. 3 Visual analog pain scale ............................................................................... 30

Figure 2. 4 Verbal numeric rating scale .......................................................................... 31

Figure 2. 5 Verbal descriptor scale ................................................................................. 31

Figure 2. 6 Wong-Baker faces pain rating scale ............................................................. 32

Figure 2. 7 Field theory model ........................................................................................ 37

Figure 2. 8 Linking of the study framework with field theory model............................. 38

Figure 3. 1 Provinces of Jordan ....................................................................................... 83

Figure 3. 2 Theoretical framework of the present study .................................................. 90

Figure 4. 1 Histogram and normal probability plots ..................................................... 121

Figure 4. 2 Linearity graph............................................................................................ 122

Figure 4. 3 Homoscedasticity test ................................................................................. 123

Figure 4. 4 A two-step process of PLS path model assessment .................................... 137

Figure 4. 5 Measurement model ................................................................................... 139

Figure 4. 6 The structural model with moderator (full model) ..................................... 148

Figure 4. 7 The moderating effect of patients‘ barriers on the relationship between

attitude towards pain management and pain management practices........... 155

xv

LIST OF APPENDICES

Appendix page

Appendix A Approval letter from Universiti Utara Malaysia to start data collection .. 242

Appendix B Approval letter to collect data from Military Hospitals (King Hussein

Medical Center & Prince Hashem Bin Al_Hussein hospital) ................... 243

Appendix C Approval letter to collect data from hospitals belonging to Jordanian

Ministry of Health ..................................................................................... 244

Appendix D The researcher‘s access card to the Military Hospitals (Security Clearance),

clarifying the beginning and ending dates ................................................ 255

Appendix E Survey Questionnaire ................................................................................ 256

Appendix F Statistical normality test ............................................................................ 264

Appendix G The levels of nurses‘ pain management practices .................................... 269

Appendix H The complete ranking orders of pain management practices ................... 273

Appendix I Indicators loadings after individual item reliability ................................... 274

Appendix J Indicators loadings after convergent validity ............................................ 277

Appendix K Indicators loadings after discriminant validity ......................................... 279

Appendix L Cross-loadings measure based on Chin (1998) ......................................... 281

xvi

LIST OF ABBREVIATIONS

AHCPR Agency for Health Care Policy and Research

AMDA American Medical Directors Association

BPS British Pain Society

CME Continuous Medical Education

CMV Common Method Variance

EM Expectation–Maximization

IASP International Association for the Study of Pain

IM Intramuscular

JCAHO Joint Commission on Accreditation of Healthcare

Organizations

JMoH Jordan Ministry of Health

JRMS Jordanian Royal Medical Services

JUH Jordan University Hospital

KAH King Abdullah University Hospital

KAP Knowledge-Attitude-Practice

MOH Ministry of Health

NSAIDs Non-Steroidal Anti-Inflammatory Drugs

PLS Partial Least Squares

ONS Oncology Nursing Society

PRN pro re nata, a Latin phrase meaning "as needed"

PSUs Primary Sampling Units

RMS Royal Medical Services

RNAO Registered Nurses Association of Ontario

xvii

LIST OF ABBREVIATIONS (CONTINUE)

SASA South African Society of Anesthesiologists

SEM Structural Equation Modeling

SPSS Statistical Package for Social Sciences

TPB Theory of Planned Behavior

UNRWA United Nations Relief and Works Agency

VIF Variance Inflation Factors

WHO World Health Organization

1

CHAPTER ONE

INTRODUCTION

1.1 Background of the Study

Pain is one of the most common symptoms experienced by patients (Clinical Standards

Advisory Group [CSAG], 1999; Gloth, 2001; Horbury, Henderson & Bromley, 2005;

Strong, Unruh, Wright, & Baxter, 2002; Van den Beuken-van Everdingen et al., 2007).

Approximately 79 percent of hospitalized patients is suffering from it (Lui, So & Fong,

2008). According to the International Association for the Study of Pain [IASP] (2012, p.

1), pain is defined as ―unpleasant sensory or emotional experience associated with actual

or potential tissue damage, or described in terms of such damage‖.

Nurses are not the only health care providers responsible to relieve a patient‘s

pain (Government of Western Australia Department of Health, 2013; McMillan, Tittle,

Hagan, Laughlin & Tabler, 2000), but they have a key role in managing the patient‘s

pain (Lewthwaite et al., 2011; Ung, Salamonson, Hu & Gallego, 2015; Zalon, 1995).

This owes to the fact that the nurses are in a central position between the responsible

physicians and their patients (Jacox et al., 1994; Lellan, 1997; McCaffery & Pasero,

1999; Registered Nurses Association of Ontario [RNAO], 2013; Schafheutle, Cantrill, &

Noyce, 2001). Furthermore, the nurses spend most of their time with patients to offer

appropriate health care services (Coulling, 2005; Lui et al., 2008). One of the most

recurrent health care services provided by the nurses is pain management (Brown,

Bowman & Eason, 1999), so the nurses should handle it as the ‗fifth vital sign‘

alongside blood pressure, temperature, breathing and pulse rate (Merboth & Barnason,

The contents of

the thesis is for

internal user

only

180

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